07010069 CITY OF CUPERTINO
BU
ILD.`JG DIVISION PEMT
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BUILDING ADDRESS: PERMIT NO.
7818 ROBINDELL WY JAMES & MARILYN 1-1 A 13 S 14M A DI 02L11 nnAg
PERMIT iSSUE DATE
OWNER'S NAME:
JAMES & MARILYN HARSHMAN 01/11/2007
SNE: SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
0 p LICENSED CONTRACTOR'S DECLARATION Job Description
WU EI hereby affirm that I am licensed under provisions of Chapter 9(commencing INSTALL TANKLES S WATER HEATER AND INSTALL NEW GAS
Z„ with Section 7000)of Division 3 of the Business and Professions Code,and my license is
=y in full force eClaandeffect. LINE TO SERVICE THE WATER HEATER
�?
License Class Lic.#
t O Date Contractor
E ARCHITECTS DECLARATION
cz U I understand my plans shall be used as public records
DWA.
=pin Licensed Pmfcssional
�m OWNER-BUILDER DECLARATION
�<M I hereby affirm that 1 am exempt from the Contractor's License Law for the
r C O following reason.(Section 7031.5,Business and Professions Cade:Any city or county
t$ff which requires a permit to concoct,alter,improve,demolish,or repair any structure
y Z} prior k)its issuance,also requires the applicant for such permit to file a signed statement $ Ft.Floor Area Valuation
_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q $1200
[—$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y .. that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 621903? Number Occupancy Type
not more than five hundred dollars(5500).
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law dots not apply to an owner of
property who builds or impmves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for We.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
()owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractar(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under B&P C for this reason
Ownv YOB� , P �DECLARA
te�j WORD F3t'S O PEN ATIO /
ereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workci s Compensation Insurance carrier and Policy number are:
Carrier. Policy NO.:
CERTIFICATE OF EXEMPTLON FROM WORKERS'
COMPENSATION INSURANCE
(rhis section need not be completed if the permit is for anc hundred dollars($100)
or less.)
I certify that in the performance of the work fo which this permit is issued,l shall not
employ any person in any mann so be me
r ccs to the Workers Compensation
Laws oC Cali ice Dare
Applicant
NOTICE T4to :If, I)er making this Ccrtifcatc of Exemption,you should
become su the orker's Compensation provisions of the Labor Code,you must
,J 0 forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
fxthe work for which this permit is issued(Sec.3097,Civ.C.)
Gil Q Lender's Name
aLender's Address
V 0 1 certify that I have read this application and state that the above information is
GL" CO CL I agree to comply with all city and county ordinances and state laws relating to
0 V building concoction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
W
(We)agree to save,indemnify and keep harmless the City of Cupertino against
tE ty liabilities,judgments,costs and expenses which may in any way accrue against said City /
V Z in consequence of the granting of this permit.
►� APPLICANT UNDERSTANDS AND WILL QGMPLY WITHALL N -P NT Issued by: Date f
SOU GULATIO
Re-roof:
Signaturt o#Aplificandtontractor ate
HAZARDOUS MATERIALS DISCLOSURE Type of F oof
Will the applicant or future building occupant store or handle hazardous material
as dciincd by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roof;shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new:naterials for inspection.
District?
❑Yes W4.1
1 have read the hazardous materi requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code, ohs 2 5,25533 and 25534.1 understand that if the building
does not curtcntly have a t it is my responsibility to notify the occup t of the
requircmcu tCh in prior to issu of a Cc I, of Occ ancy Date
Signature of Applicant
win r or thorn agent D All roof coverings to be Class"B"or better
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family parent,spouse or child) will perform:
A. _ All the work author ized by this permit
B. _ A portion of the we r�
C. bone of the work
If B or C is checked,c:)nplete 2 or 3 below.
2. A state licensed contractor will be hired.to do:
A. All of the work
B. _ portion of the we r (complete section below)
I
Contractor Address/City Phone # State License # Type of work to
3. — I will utilize unlicensed person(s) ether than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' corn_pensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City . Phone Number Type of work to be
performed
................. ..............................................................I................................................. .........
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information(reverse side).
Property IOwner's Signature: -� �. Date:
Job Address: / O i✓I i HU Permit#
I
Any changes to the information provided on this form shall be submitted to the Ci!y of Cupertino Build
Department.
I I
I i I i
CITY OF (:
CITY OF CUPERTINO
a(tz-
CM OF PERMIT APPLICATION FORM
CUPERTINO
Quantity Fee ID Fee Description Fee Group ,
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Corrin. Housing Mit. Fee BUILDING
BNUCOMME Ncw Comm Electric ELECTRICAL
BNUCOMMM Neve Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTIME In 3pection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE I,'ld Permit Fees BUILDING
BPFIXTURE Pblg Fixture PLUMBING
BPGAS Ga:;Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Ph n Check Add Multi BUILDING
BPLANCKREP Plan Check Repeat Fee BUILDING
BpREplpE R e i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn Sprinkler/Backflo PLUMBING
BPSTORM 3torm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER Install/Alter Water Pipe PLUMBING
BPWHEATER Nater Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER AiC Unit> 10,000 cfm MECHANICAL
BREMAMHAN AUnits<= 10,000 cfM MECHANICAL
/C
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Re to Furnace> I OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Zepair/Alter Heating MECHANICAL
BREMRESAPP R,-model Res Appliance ELECTRICAL
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awyoCITY OF CUPERTINO
PERMIT APPLICATION FORM
CUPEkTINO
Quantity Fee ID Fee Description Fee Group
BREMSIGNAD Rridl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial _ BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Inspection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary Bldg Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanical sq. foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Change BUILDING
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